Category Archives: Health Care

Unpaid Bills, Debt Collection, and Hospital Profits

Carlos Ortiz. Photo credit: Wall Street Journal

Carlos Ortiz underwent tests last year at Mary Washington Hospital in Fredericksburg for dizziness stemming from an inner-ear problem. When the 65-year-old uninsured gardener couldn’t pay his $15,000 bill, the nonprofit institution took him to court. Mary Washington was suing so many patients that day that the circuit court had cleared the docket to hear all the cases.

As it turns out nonprofit hospitals are more likely than for-profit hospitals to garnish patients’ wages to collect their bills, according to a study of Virginia hospitals published Tuesday in the Journal of the American Medical Association and reported upon by the Wall Street Journal. In 2017 Virginia nonprofits filed 20,000 lawsuits against patients for unpaid debt.

Remarkably, the study found, nonprofits are more likely than for-profits to file lawsuits against patients for unpaid debt. These numbers do raise fundamental questions about Virginia’s social compact with its nonprofit hospitals. But hasty judgments are not in order. Continue reading

The Health Care Crisis: We Have Met the Enemy, and It is Us

Image source: The Atlantic

Thought experiment: What if you had the same health care system as Sweden…. but populated it with Americans? Would you have the same health outcomes as Sweden? Would health care as a percentage of the economy cost the same?

Writing in The Atlantic, David H. Freedman argues that high costs and poor medical outcomes are driven not only by the structure of the health care system but the expectations and behaviors of Americans.

We ought to consider the possibility that if we exported Americans to … other countries, their systems might end up with our costs and outcomes. That although Americans (rightly, in my opinion) love the idea of Medicare for All, they would rebel at its reality. In other words, we need to ask: Could the problem with the American health-care system lie not only with the American system but with American patients?

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Oops, We Did It Again

What a shock! Virginia’s Medicaid expansion isn’t working out as planned. Today we learn that Virginia’s private hospitals, which are paying a tax to defray the state’s 10% share of expansion (Uncle Sam pays the rest), is on track to receive only 78% of the Medicaid revenue they expected, reports the Richmond Times-Dispatch.

The big question is whether the shortfall is a one-time event caused by a slower-than-expected rollout of the program or a permanent feature of the healthcare landscape.

Department of Medicaid Assistance Services (DMAS) estimated that the influx of 300,000 to 400,000 Medicaid patients would increase hospital industry revenues by $247 million in the second half of the 2019 fiscal year. So far, the actual net increase is on pace for $192 million for the six-month period. The hospital lobby agreed to the tax in the expectation that a surge in Medicaid revenue would more than offset it.

“We’re rolling out a little bit more slowly than anticipated,” said Chris Gordon, chief financial officer for DMAS. “We’re continuing to monitor and adjust our forecast. We continue to learn from experience.”
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Long-Term Care: A Great Bet If Made Long Ago

It is just like your econ professor told you – insurance is nothing but a bet.  It is a bet you often don’t want to win, but in one field you had a great chance of winning simply by hanging around and continuing to breathe.  That field is (or at least was) long-term care coverage.

Two top executives from major insurers told the State Corporation Commission last week just how badly their companies calculated the risk on long-term care decades ago.  They were seeking to explain the major premium increases their companies are seeking here in Virginia and all around the country in a proceeding previewed (here) in March on Bacon’s RebellionContinue reading

Are PBMs Killing Pharmacies, Hiking Medicaid?

Stoney Creek Pharmacy, Nellysford, VA

A form letter mailed this month announced the death of another local independent pharmacy, this one in the bustling community of Nellysford.  Residents of Nelson County’s Rockfish Valley, including those in the large Wintergreen community, will join plenty of other rural areas in the U.S. without a pharmacy close by.

“Very few independent pharmacies show a profit now unless they sell CBD oil, still unproven, do compounding or find other niche markets that small populations…cannot support,” wrote pharmacist Bob Ladd, who first owned the business in 1988, got out and then bought it back in 2017 in a last ditch effort to make it viable.  A new Dollar General store nearby was a major blow to his non-prescription sales, he added.  Continue reading

Bacon Bits: A Little Bit of This, a Little Bit of That

Safe hospitals. I’ve long maintained that the best thing you can do for your health is stay out of hospitals — 160,000 deaths occur annually across the country from avoidable medical errors monitored by the Leapfrog Hospital Safety Grade. Fortunately, Virginia hospitals are safer than most. The Old Dominion has the second highest percentage — 53% — of hospitals in the country of hospitals meriting Leapfrog’s A rating. In Maryland only 25% of hospital scored an A, and in Washington, D.C., there are no A-rated hospitals, reports the Richmond Times-Dispatch.

Expanding hospital. Speaking of  hospitals, Carilion Roanoke Memorial Hospital has just announced a $300 million expansion that includes a new tower to care for emergency and heart patients, a new behavioral health hospital across the street, a parking garage and a pedestrian skyway to connect it all. The expansion is part of Carilion’s plan to invest $1 billion over the next seven years, according to the Roanoke Times. Roanoke Memorial scored a B in Leapfrog’s ranking, incidentally. Roanokers might legitimately inquire if some of that $300 million could be better spent on preventing avoidable medical errors.

Bye, bye, Jeff, baby. The Commonwealth Transportation Board unanimously voted yesterday to allow Arlington County to change the name of Route 1 from Jefferson Davis Highway to Richmond Highway, reports the Washington Post. The United Daughters of the Confederacy had spearheaded the naming of the highway after the president of the Confederate States of America, as a “direct and antagonistic response” to the establishment of Lincoln Highway across the northern states, said Arlington Board Chair Christian Dorsey. Continue reading

Bacon Bits: Alexa, Graphene, Nurse Practitioners

Hey, Alexa, does Amazon have any job openings for its Alexa project? Amazon has posted its first job listings for its new Arlington County headquarters and is moving two vice presidents from Seattle to Arlington, reports the Washington Post. One will oversee workforce development, and the other will run a technical team focused on international growth of its virtual assistant Alexa.

Commercializing one of the world’s most awesome materials. Graphene is 200 times stronger than steel. It is superb at conducting heat and electricity. And it’s incredibly pliable. Now the Carbon Research and Development Co. is building a Graphene Research Center in Wise County with the backing of a $1.5 million loan from the Virginia Coalfield Economic Development Authority. The Center, which is focusing on applications in the manufacturing center, is collaborating with Virginia Tech, reports the Roanoke Times, to derive the carbon-based material from coal.

First nurse practitioner licensed under new law. Continue reading

Bacon Bits: Rural Development Edition

Seeding entrepreneurship. The Virginia Coalfield Economic Development Authority has approved $180,000 in seed-capital grants up to $10,000 for businesses that have been operating less than a year and have fewer than 10 full-time employees. The new businesses are projected to create $770,000 in total private investment and create 135 full-time and part-time jobs. Assuming the businesses deliver on their investment and jobs — not to be taken for granted — this looks like a promising approach to economic development. Since it started two years ago, reports the Bristol Herald-Courier, 53 businesses receiving micro-grants have generated $3.1 million in private investment and created 542 full- and -part-time jobs. Beats subsidizing an out-of-state company to build a light manufacturing plant and then shut it down 10 years later.

Addressing the doc shortage. Southwest Virginia has a chronic shortage of doctors, nurses and other health care providers. The United Company Foundation in Bristol is issuing a $1 million challenge grant to the Edward Via College of Osteopathic Medicine in Blacksburg to lower medical school debt for doctors who agree to practice in Southwest Virginia, reports the Roanoke Times. Two $40,000 scholarships will be awarded this spring to third-year medical students. After they complete their residencies, they will be required to work for three years in the region.

To plug the broadband gaps, first you have to find the broadband gaps. Continue reading

Medicaid: Report The Taxes Along With The Growth

Expansion tracking on the Virginia DMAS website. Click to expand, web version is here.

Virginia makes is easy to track the growth of Medicaid enrollment since the decision a year ago to expand coverage but tracking the tax dollars behind the scenes is another matter.

The new enrollment expansion dashboard on the Department of Medical Assistance Services website is updated every couple of weeks, with the April 4 report showing just under 260,000 people added to the program since late last year.  The City of Salem has added the fewest, only 34 new recipients, while Fairfax County has added the most at 18,220.  The advertised goal for expansion was 400,000 persons, so probably there are more to come.  Continue reading

Addiction as a Workforce Development Issue

How ubiquitous is drug abuse in Virginia’s workforce? In western Virginia, it’s mind-numbingly pervasive.

“In many environments, as many as 50 percent of employee applicants who are eligible on the basis of their training, skills, and background fail to be employable because they fail to pass a drug screen,” Dr. Bob Trestman, chairman of psychiatry for Carilion Clinic, told Roanoke-area employers in a panel talk yesterday, reports the Roanoke Times.

Most employers have Employee Assistance Programs but Trestman said employees are reluctant to use them because addicts are stigmatized. “We need to think of them as people with an illness. Then we can reframe how we approach care and treatment and engage and support them in the workplace safely.” Continue reading

Virginia’s “Secret” Medical Marijuana Program

The doctor who should be governor. State Sen. Siobhan Dunnavant is a Republican from Henrico County. She is also a practicing physician. In this year’s General Assembly session she put forth SB1557 which expanded last year’s so-called “Let Doctor’s Decide” legislation (HB1251).

What’s new? The 2018 legislation (HB1251) authorized licensed medical providers to prescribe CBD and THC-A oil “to alleviate the symptoms of any diagnosed condition or disease determined by the practitioner to benefit from such use.” CBD, or cannabidiol, is a naturally occurring compound found in the resinous flower of marijuana plants. It is used to treat a variety of maladies. It is non-intoxicating. THCA, or tetrahydrocannabinolic acid, is the non-psychoactive acid form of THC found in marijuana plants when raw. It is also non-intoxicating unless it is heated. Once heated, THCA releases THC which is intoxicating.  The 2018 legislation restricted THCA oil to contain no more than 5 mg of THC (the psychoactive component of marijuana). Continue reading

Bacon Bits: Economic Research Edition

I periodically check the research papers coming out of the National Bureau of Economic Research (NBER) because they often address issues of interest to Bacon’s Rebellion. The research is far more rigorous from a methodological perspective than the work product of special-interest and advocacy groups, hence more worthy of serious consideration — even when it leads to public-policy implications I don’t like! Here are some quick hits from recent studies:

“The Effects of Rent Control Expansion on Tenants, Landords, and Inequality: Evidence from San Francisco”
“We find rent control increased renters’ probabilities of staying at their addresses by nearly 20%. Landlords treated by rent control reduced rental housing supply by 15%, causing a 5.1% city-wide rent increase.”

Implications: Rent control benefits existing renters but punishes newcomers entering the rental marketplace. Can you say “increasing homelessness?” As zoning codes and other restrictive policies aggravate the supply/demand imbalance here in Virginia, will our politicians avoid the temptation to impose rent controls? Continue reading

Boomergeddon’s Coal Mine Canary Sings Warning

Angry consumer complaints are starting to appear on a growing case record at the State Corporation Commission, which opened the case on its own authority to demand insurance company presentations on the long-term care product market and its history of massive rate hikes.

A typical comment so far: “This frankly, appears to be a ploy of the insurance providers to raise rates so high that they will be completely unaffordable, everyone will drop their policies and the insurers will be able to exit the long term care industry. Consumers must be protected from these predatory practices and these rate hikes must be denied by the SCC.”  Others (the record is here) detail years of steady premium increases and benefit reductions.   Continue reading

Health Care and the Oppression Narrative

County health rankings. Source: Robert Woods Johnson Foundation

Correlation does not equal causality. That’s a fundamental tenet of statistics, but the concept apparently is so rarefied that a Virginia Mercury article based the Robert Wood Johnson Foundation’s County Health Rankings appears to be unfamiliar with it. The result is a headline — “In Virginia, health outcomes follow geographic and racial lines” — that has become standard fare in the ongoing Oppression Narrative embraced by most of Virginia’s media outlets. By misdiagnosing the problem, the Oppression Narrative does a grave dis-service to Virginia’s poor and minorities.

Writes the Virginia Mercury today:

More than 20 percent of Virginia’s black, American Indian and Hispanic populations report poor or fair health, compared to 14 percent of the state’s white residents. …

Year over year, the rankings essentially tell the same story: Virginia’s healthy counties, many of which are nestled in the northern part of the state, remain healthy, while its unhealthy localities, clumped together in the south and southwest, continue to struggle with poor outcomes. …

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Squeezing the Most from Every Health Care Dollar

Teaching healthy cooking at Health Brigade’s Food Farmacy.

Medicaid expansion in Virginia is forcing Virginia’s free clinics to make a fundamental choice. Should they participate in Medicaid or not?

Accepting Medicaid payments would provide a new source of funding for clinics, which don’t charge for medical services, and would allow them to continue treating patients who qualify for Medicaid and would otherwise need to seek primary care services elsewhere. But Medicaid generates extensive, complex regulations which must be handled by paid administrative staff.

Health Brigade, formerly known as the Fan Free Clinic, has made the strategic decision not to participate. The clinic, which serves the Richmond area, will forego significant revenue and lose many patients. But there will be no lack of patients to take their place, says Wendy Klein, the clinic’s medical director. While Medicaid expansion will provide insurance coverage to up to 400,000 Virginians, an estimated 300,000 still will have none.

“We take care of people with no insurance and no Medicaid,” says Klein. “There are still a lot of poor people who don’t qualify for Medicaid. Even with expansion, people will fall between the cracks.”

The go/no go decision on Medicaid cuts to the heart of the free clinic business model. It determines the populations they serve, and it shapes their organizational structure. Health Brigade, which is run by socially progressive non-profit entrepreneurs, has concluded that it can accomplish more good as a scrappy, low-overhead outfit filling gaps in the safety net rather than as a cog in the bureaucratic healthcare system. While cultural conservatives may feel uncomfortable with some of Health Brigade’s priorities — it serves transgender patients and illegal immigrants — anyone who believes in a strong civil society will find much to admire in the organization.  Continue reading